Effect of task-oriented counselling on knowledge and attitude towards contraceptive practices among postnatal women

INTRODUCTION

The world population is likely to increase by 2.3 billion over the next 30 years, passing from the current 7.6 billion to 9.9 billion in 2050.¹ India is the country with the greatest projected population increase between 2018 to 2050 by 308.8 millions.¹ In 2016, family planning saved the lives of 43,000 mothers in India and prevented 38 million unintended pregnancies, yet one in five women in India who want to delay pregnancy are not using a contraceptive method.² Leading economists report that investment in family planning generate higher social, economic and environmental returns than nearly all other development priorities.³ Voluntary family planning allows women and their families to choose when they would like to have children. Adequately planning for and spacing births saves the lives of mothers and infants and improves child nutrition.⁴ The objective of our study was to evaluate the effect of task oriented counselling on knowledge and attitude towards contraceptive practices among postnatal women in a teaching hospital in coastal southern India.

METHODS

Study area

A cross-sectional questionnaire based survey conducted in the postnatal ward of a tertiary teaching hospital.

Study period

Study was conducted for the period of one year i.e. From December 2018 to November 2019.

Study subjects

All postpartum women present in the postnatal ward after delivery at tertiary care teaching hospital were included in the study. Simple random sampling technique were used.

Inclusion criteria

Healthy consenting post partum women belonging to age group of 18-40 years and women whose pregnancy has crossed the period of viability i.e. 28 weeks in the hospital set up and have had normal vaginal delivery or lower segment caesarean section were included.

Exclusion criteria

Women who have had still-birth or Intra-uterine death of the foetus, women who were admitted in Intensive Care Unit (ICU) or High Dependency Unit (HDU), and women with known/newly diagnosed psychiatric disorders were excluded.

Sample size

To calculate sample size, technique of estimation of single proportion is used:

n= Z² _1-α/2 P (1-P) d²

=96.04≈100

α= confidence level (95%), d=precision (10%), P=anticipated proportion of knowledge (50%).

So, the minimum sample size required was 500.

This cross-sectional study was conducted in the departments of Obstetrics & Gynaecology of a teaching hospital in southern India. The hospital serves the general community, and represents the local population. Five hundred and twentyone healthy and consenting postpartum women between the age group of 18-45 years were recruited by simple random sampling technique on their 2^nd and 3^rd postnatal day after vaginal and caesarean delivery respectively. Women with history of psychiatric disorder or still birth and those admitted in Intensive Care Unit (ICU) or High Dependency Unit (HDU) were excluded from the study. Questionnaire was prepared and validated after expert review and the pilot study. Validated questionnaire was used for the study containing demographic proforma, structured knowledge as well as attitude questionnaire, and opinnionaire on practice and preferences of contraceptive methods. Ethical clearance was obtained from the Institutional Ethics Commmittee. After evaluating their initial responses, 30 minutes face to face counselling was done using task-oriented communication method.⁵ This was followed by repeat assessment of responses in the post-counselling questionnaire. SPSS 21 was used for statistical analysis. Pre and post-counselling data was compared using Chi-square Test. Effect of socio-demographic characteristics on the pre-existing behaviour towards contraception was analysed by Likelihood ratio. A p value of <0.05 was considered significant.

RESULTS

Of the 521 study participants, 495 (95%) women were literate, with 234 (45%) being graduates, 385 (74%) women followed Hindu religion, 380 (73%) were homemakers, and 318 (61%) were above the poverty line. Half of the women belonged to the rural areas. Of all the women, 406 (78%) were between the age group of 18-30 years, and 78 (15%) were married before the age of 20 years. Husbands of most women, 516 (99%) were literate, with 219 (42%) being graduates and 125 (24%) having monthly incomes ranging from Rs. 11,000-15,000 (USD 130-180). We found that before counselling, awareness of family planning was significantly associated with age, maximum being in those between 21-25 years, literacy, and working status of the women and those above the poverty line, as shown in Table 1.

Of the 521 women, 385 (74%) got pregnant in the first 2 years of their marriage, 219 (42%) had two children, and 438 (84%) were breastfeeding their newborn child. Of all, 234 (45%) of these women had already used a family planning method in the past, one-third of which preferred male condoms, and one-third stated that they used various forms of contraception. Of all, 287 (55%) of women didn’t use any family planning method, and 198 (38%) wanted more children. Of the total, 234 (45%) were reluctant to have more children, half of whom had completed their families. Family planning was a combined decision of the couple in 323 (62%) of them. Table 2 indicates the significant positive change in knowledge and awareness about contraception among these women after the counselling was provided in the postnatal period. Fear of polygamy among their husbands and that of suffering domestic violence, which influenced the use of family planning methods, did not improve even after counselling.

NS=Not Significant

Statistically significant change in the attitude regarding contraception after counselling is shown in Table 3. Table 4 shows the willingness and plans to change the practice regarding family planning after counselling.

These women already had good understanding of the small family as a happy family (81%) and were aware of the need for spacing among children which did not change significantly after counselling (96%). They did not show any significant change in their knowledge regarding the cost of the various contraceptives in the hospital, neither was there any change in their willingness to recommend the family planning methods to their friends. Sixty seven percent of the women acknowledged the presence of health care providers at the community level for providing family planning services. However, only half of the women found these services useful. Forty two percent of the women said that various contraceptive methods were explained to them by the health care providers, but only one fourth of the women understood them and complied with the advice given to them by these service providers.

Women from urban area, and those above poverty line showed willingness to adopt contraceptive practices as compared to the rural area, which was however, not statistically significant. Awareness and willingness to adopt family planning was not associated with the duration of married life, education status of the women as well as their religion.

DISCUSSION

Birth control and family planning services are an integral part of the government programmes in the developing countries of south east Asia. Postnatal period is the time when the mothers have experienced pregnancy and childbirth and might want to think about contraception. It gives an opportunity during their hospital stay for counselling regarding family planning. Studies have not been published regarding the counselling for contraception in the postnatal period.

Strategies to increase the contraceptive use must include improving delivery of correct and adequate information about the availability of contraceptive methods.⁶ For contraceptive usage, woman’s will and motivation is necessary. Education of women is considered to be the most important factor in decision making.⁷ In our study, result showed that 87% women had knowledge about contraception, which increased further after counselling. This is slightly less than that seen by studies conducted at Lahore (97.4 and 99%) and by Tuladhar et al (93%), with more than half of our women knowing more than five methods of contraception.^8-10 Willingness for contraceptive practices in 72% of our women was independent of their socioeconomic status. However, lack of knowledge has also been reported by Osemwenkha with 54.3% women being aware, which however increased to 93% after counselling.¹¹

Our analysis shows that media was the major source of knowledge regarding family planning even prior to the counselling which did not increase significantly after counselling. Knowledge about the source of information of contraception was inadequate in our study and improved to 88% after counseling. This will help them to plan future pregnancies as they can visit doctor or health care provider at the hospital for suitable contraception. The main source of knowledge for women in our study was television (59%), similar to the study by Tuladhar et al and Fikree et al.^10,12 who reported mass media with 55% contribution, whereas Srivastava et al found health care providers providing maximum contribution.^10,13 Similarly, study from rural Nepal also reported an exposure to electronic media messages as the main factor for use of family planning methods among women.¹⁴ Health workers have been found to contribute in a major way in disseminating information regarding contraception in a study in Ethiopia, whereas social circle was the major source of knowledge followed by television and health workers seen in Nigeria, and a study from India.^15,16,13 The pre-existing knowledge of side-effects of various family planning methods was 29% in our study compared to the study by Tuladhar et al (63%).¹⁰ However, the knowledge regarding side effects increased to 57% after counselling.

Seventy-eight percent of our women were willing for contraceptive practices which is similar to the report by Tuladhar et al and slightly more by Sherpa et al (87.5%).^10,17 Similar result was seen in the study done by Sonia Naqvi et al.¹⁸ However, this attitude varies with the local beliefs in the population with only 48.5% of the women in north-eastern part of India with favorable attitude in the study by Pegu et al and 87.5% in the southern coastal Karnataka of India.^19,17

After providing counselling and guidance, 97% of the women thought that contraception was beneficial, indicating that intervention at the time of post natal stay in the hospital can help to create consciousness and initiate the usage of contraception in women immediately or in near future. Though the attitude towards small family norm was mainly positive (81%) in our study, less number of women were complying with it. After making them aware about the advantages of small family, 96% were willing to follow it. It is shocking to observe that in our study half of the couples had never used a contraceptive before, as compared to only 8% in the study by Young et al.²⁰

The present study highlights a very low contraceptive usage which could be a reason for a high fertility rate in this region of India. The various reasons for this are mainly illiteracy, ignorance, social and religious taboos, and inadequate social welfare services. Two Indian studies showed 55% and 44.6% of non-users, which are close to the results of our study.^13,21 Partner’s opposition and lack of knowledge were the reasons found for low contraceptive use in other studies.^22,23 According to the Pakistan Reproductive Health and Family Planning Survey 2000-2001, as well as the survey in the Eastern Turkey, husband’s disapproval was the main factor for not using any family planning method among the married women.^8,24

Of the total, 66% of the women in our study were eager to follow family planning methods in the future which was lower compared to the study conducted by Yilmazel et al and Choudhary et al in which 86.4 and 90.5% of pregnant women respectively stated that they would use a contraceptive method after childbirth.^25,26 In our study, 89% of the respondents who had not adopted any contraceptive methods, were interested to use one of them after appropriate counselling. Only 62% of the women discussed family planning with their husbands, stating a communication gap among the couple despite their literacy. After counselling regarding having an open communication with the husband, 83% women agreed to have a dialogue with their husbands regarding the socio-cultural, economic or any religious factors preventing them from using family planning methods and thus controlling major issues like divorce, pressure of having more children and domestic violence to have a happy and healthy family, both physically and mentally. In the present study, 59% of respondent’s husband disapproved family planning, similar to 54% of results in a study conducted by Etuk et al.²³ A similar pattern was also found in Eastern Turkey, where husband’s disapproval was the main factor for not using any family planning method among married women.²⁵ However, husband support for family planning was significantly higher in a Jordanian study.²⁷ Attitude of husband was found to be an important predictor for contraception use. In rural areas, husband being the dominant member, plays the pivotal role in approving the family size and contraceptive practices. Education is, therefore, considered to improve the ability of women to resist subjugation and to acquire greater power in decision making. Also, education of the husbands need to be considered.

Most of the reproductive age women who are expecting, visit hospitals for regular antenatal checkups or for delivery but do not approach any health care provider or doctor regarding their need for contraception and are not aware about its availability at the hospital. The role of health personals in the awareness programme of family planning was not found to be satisfactory in our study. Out of 67% women who had family planning services available in their community, only 25% of them complied with the counselling received from them. More dynamic and frequent interjecting programs can be developed consisting of schemes in the form of children’s education, health insurance or monthly financial support to the families practising family planning. Government programmes supporting permanent sterilization either in man or woman who had completed their family to follow small family norm can be reemphasized and follow up of women using temporary methods of contraception by the health care providers will ensure the compliance as well as help the women to plan their families under guidance and professional care.

The strength of this study was that it involved the opportunity for counselling during the postnatal period. It also studied the association between the existing knowledge about contraception with the socio-demographic factors like age at marriage, area of residence, education status, socio-economic status and working status of the women and interestingly found that there was no significant association between them.

This reflects the whole population as it covered the postpartum women of southern coastal region in the hospital serving the community. However, the research could have been better if the same women were tested after 6 months to study the long term change in attitude in the community, thus evaluating the need for further reinforcement sessions. After creating awareness regarding contraception among the women, follow up sessions could have been scheduled with them to study their compliance and practices. Information regarding women practicing natural contraceptive measures as well as knowledge about lactational amenorrhea was not included. Factors encouraging women to use family planning need to be addressed in further research. Also, male partners were not directly involved in the study. Information regarding antenatal counselling sessions was out of the scope of this study.

CONCLUSION

The study reveals good knowledge and favourable attitude of rural women towards contraception. Despite having good knowledge and positive attitude, there are some factors like desire for large family, pressure from husband, religious concern etc. leading to non-use of contraceptives. However, their acceptance after counselling was high, thus showing significant impact of counselling. Contraceptive knowledge and practice was influenced by media exposure and partner opposition. Women education and counselling of couples should be reinforced in the postnatal period which can play an important role to adopt family planning methods. This can be brought about by facilitating the access to more information, education and communication with the reproductive age couples, and improved social and welfare services.

ACKNOWLEDGEMENTS

We would like to thank the Indian Council of Medical Research.

Funding: This work was supported by the Indian Council of Medical Research. No: 21/1/2017-HRD-STS

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee (No. INST./EC/053/2017-18)

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